The importance of visualizing the ureter before performing a pyeloplasty

Records were reviewed of 100 patients who underwent an operation for ureteropelvic junction obstruction from 1978 to 1989: 14 cases were bilateral and 17 were antenatally diagnosed. The ureter was opacified preoperatively in all but 1 patient: in 65 by retrograde pyelography, in 18 by antegrade pyelography, either through a nephrostomy tube with which the patient was referred or during a Whitaker test, in 9 by vesicoureteral reflux seen on voiding cystourethrography performed before an operation for ureteropelvic junction obstruction and in 7 by an excretory urogram. Of the 65 patients who underwent retrograde pyelography 29 had a discrete area of narrowing. However, 36 patients had something more, including a longer segment of narrowing (13), tortuosity of the upper ureter (8), more than 1 area of narrowing (11), high insertion of the ureter on the renal pelvis (3) and compression of the ureter by the lower pole of the kidney (1). In 10 patients referred for reoperation after failed pyeloplasty there was narrowing of the ureter below the level of the prior pyeloplasty. Although indications for retrograde pyelography are fewer today with the various modern imaging modalities in current use, we believe a retrograde examination should be performed before pyeloplasty if the ureter has not been well shown by other means. The retrograde catheter should be small and soft, so as to create no edema or other injury to the lower ureter. The study is done with the patient under the same anesthesia as the pyeloplasty and not at a previous time. All 114 pyeloplasties in these 100 patients were successful.